Reminder
A case presentation is a clinical communication tool.
It is not a performance of diagnostic ignorance.
The misunderstanding
Many students hide known diagnoses when presenting cases — believing
that revealing it is somehow wrong, or that a good presentation must
reconstruct the diagnostic journey from scratch. It does not. Hiding
a known diagnosis is inefficient, confusing, and clinically
unrealistic.
The principle
State what is known. Focus on why the patient is here today.
Challenge the diagnosis only when the facts demand it — not as a
default, and not out of habit.
Where the confusion comes from
Lecturers sometimes use known cases to teach diagnostic reasoning —
deliberately withholding the diagnosis so students practise building
it from first principles. This is a valid teaching tool. But it is a
classroom exercise, not a model for real clinical presentation.
The Three Rules of a Case Presentation
"State what is known. Focus on today.
Challenge the diagnosis only when the facts demand it."
1
State what is known
A known diagnosis is stated upfront.
"He is a known case of transfusion-dependent
thalassaemia."
This is not cheating. This is efficient, honest clinical
communication.
2
Focus on today
The presenting concern of this visit drives the
presentation. Why is the patient here now? What has changed, or
what is expected? That is the clinical question.
3
Challenge only when demanded
Return to first principles only when the disease is
not behaving as expected — failing to respond to
treatment, presenting atypically, or not following the anticipated
course.
The Source of the Confusion
Two contexts — two different rules — do not confuse them
Why students hide diagnoses — and why it is understandable but
wrong on the ward
The classroom context and the clinical context are not the same
Both have legitimate rules. The error is applying the classroom rule
in the clinical context.
Classroom Context
Diagnostic Reasoning Exercise
Purpose: Teach reasoning from first principles
A lecturer uses a known case and asks students to present without
revealing the diagnosis. The student builds the diagnostic
argument step by step — from presenting symptoms to conclusion.
This is a valid and important teaching method.
It trains the student to reason forward from clinical
data.
The "no diagnosis" rule exists for a specific pedagogical purpose
within a controlled exercise.
In the classroom: withhold the diagnosis to practise building the
diagnostic argument. This is the exercise — not the model for real
practice.
Clinical Context
Real Ward Presentation
Purpose: Communicate to enable clinical action
A student clerks a child admitted for a scheduled blood
transfusion. The child has been on a transfusion programme for
eight years.
There is no diagnostic doubt. There is no reason to withhold
this information.
The listener needs the full picture immediately. Hiding the
diagnosis wastes time, creates confusion, and signals the student
has not understood what a presentation is for.
On the ward: state the diagnosis. Focus on today's presenting
concern. The communication serves the patient — not the exercise.
This is not a criticism of the teaching method.
Diagnostic reasoning exercises using known cases are valuable. But
students must recognise which context they are in — and switch rules
accordingly. Applying classroom rules on the ward is not caution. It
is a misunderstanding of purpose.
The Opening Statement
What it sounds like — wrong and right
— same patient, same diagnosis
Wrong vs Right
9-year-old boy, transfusion-dependent thalassaemia, admitted for
scheduled transfusion
Wrong — diagnostic concealment on the ward
Do not say
"This is a 9-year-old boy who presented with pallor and fatigue at
the age of four. Blood tests at that time showed a low haemoglobin
and microcytic picture. Further workup including haemoglobin
electrophoresis was performed and… he was eventually started on a
transfusion programme…"
Buries the known diagnosis under eight years of reconstructed
history
Forces the listener to wait before understanding the clinical
context
Adds no diagnostic value — the diagnosis is not in doubt
Never answers the only question that matters: why is he here
today?
→
Right — state what is known, focus on today
Say this
"This is a 9-year-old boy, known case of transfusion-dependent
beta-thalassaemia, under regular blood transfusion for the past
eight years. He presents today for his scheduled transfusion. Last
transfusion was three weeks ago. Pre-transfusion Hb is pending."
Diagnosis stated immediately — listener is oriented in ten
seconds
Duration and treatment context established clearly
Today's purpose stated — scheduled transfusion
Relevant current data flagged — last transfusion date, Hb
pending
The correct opening does not use more words — it uses the right
words in the right order.
The listener can act from the first sentence. That is the purpose of a
presentation.
Structure
The four elements of every correct opening statement
Model opening — read this, understand the four elements
"This is a 9-year-old boy, known case of transfusion-dependent
beta-thalassaemia, under regular blood transfusion for eight years. He
presents today for his scheduled transfusion."
1
Demographics
Age and sex. Orients the listener immediately. Two words. Never
skip it.
2
Known diagnosis
"Known case of…" — state the diagnosis precisely. Not vaguely. The
full name of the condition.
3
Treatment context
"Under regular transfusion for eight years" — duration and
management. Tells the listener the disease is established.
4
Today's reason
"Presents today for…" — the purpose of this visit. This drives
everything that follows.
The Decision Framework
When to state, investigate, or challenge
— one question, three paths
Entry Point — Ask This First, Every Time
Why is this patient here today?
State the known diagnosis first. Then ask this question. The answer
determines which path the presentation takes — and governs
everything that follows.
Path A
Expected, routine visit
Patient arrives as scheduled. Nothing unexpected. Disease
behaving as anticipated.
What to do
State the diagnosis upfront
Present today's purpose — the scheduled visit or procedure
Report relevant current parameters — Hb, last transfusion,
medications
No need to revisit the original presentation
No need to challenge the diagnosis
State · Don't challenge
Path B
Unexpected or premature visit
Patient arrives earlier than scheduled. Something has changed.
The expected course has deviated.
What to do
State the diagnosis upfront — still not in
doubt
Identify the deviation — what changed from expected?
Investigate the cause — new illness, haemolysis, bleeding?
The diagnosis stands; the question is what triggered the
deviation
State · Investigate the deviation
Path C
Diagnosis not behaving as expected
New diagnosis failing to respond. Atypical course. Facts do not
fit the label.
What to do
State the working diagnosis — but flag the
uncertainty
Return to first principles — what did the original
presentation show?
Ask: does the evidence actually support this diagnosis?
Only now is excavating the original history justified
Challenge · Return to first principles
Anchor Case 1
Thalassaemia — same diagnosis, three different presentations
🩸
Haematology · Paediatrics
Transfusion-dependent beta-thalassaemia
Scenario A — Path A
Scheduled transfusion day
Open with
"Known case of transfusion-dependent beta-thalassaemia, under
regular transfusion for eight years. Presents today for his
scheduled transfusion. Last transfusion three weeks ago.
Pre-transfusion Hb 6.2 g/dL."
Focus of today's clerking
Pre-transfusion Hb — guides transfusion volume
Chelation compliance — ferritin trend
Symptoms since last transfusion
No need to go back to age of first diagnosis.
Scenario B — Path B
Arrives two weeks early
Open with
"Known case of transfusion-dependent beta-thalassaemia.
Presents
two weeks ahead of scheduled transfusion with
increasing pallor and fatigue over five days. Pre-transfusion
Hb 5.1 — lower than his usual nadir."
Now investigate the deviation
Why did Hb drop faster than expected?
Febrile illness → infection-driven haemolysis?
Splenomegaly → hypersplenism?
Occult bleeding source?
Alloimmunisation → new antibody?
Scenario C — Path C
New diagnosis, not responding
Open with
"Diagnosed with thalassaemia last month. Transfused as
required, but remains symptomatic — Hb not maintaining as
expected between transfusions.
The diagnosis requires review."
Return to first principles
Was diagnosis confirmed by Hb electrophoresis?
Concurrent nutritional anaemia — iron, B12, folate?
Bone marrow suppression excluded?
Revisit the original presentation.
In Scenarios A and B, thalassaemia is never questioned.
In B, it is the deviation from expected course that is investigated —
not the diagnosis itself. Only in Scenario C, where the disease is not
behaving as confirmed thalassaemia should, does the student return to
first principles.
Anchor Case 2
Nephrotic syndrome — the same framework, a different disease
🫘
Nephrology · Paediatrics
Steroid-sensitive nephrotic syndrome
Scenario A — Path A
Routine follow-up in remission
Open with
"Known case of steroid-sensitive nephrotic syndrome, diagnosed
18 months ago, currently in remission on alternate-day
prednisolone. Presents for routine follow-up. No oedema. Urine
dipstick negative for protein this week."
Focus of today's clerking
Urine protein — ongoing remission confirmation
BP and growth — steroid side-effect monitoring
Steroid weaning plan discussion
No need to revisit the original presentation.
Scenario B — Path B
Presents with new oedema
Open with
"Known case of steroid-sensitive nephrotic syndrome, on
alternate-day steroids. Presents with
three days of periorbital and pedal oedema —
consistent with relapse. Urine protein 3+ on dipstick this
morning."
Investigate the relapse — not the diagnosis
What triggered this relapse?
Recent URTI or intercurrent infection — commonest trigger
Steroid compliance — was weaning adhered to?
Renal function, albumin, UPCR
Scenario C — Path C
Not responding to steroids
Open with
"Diagnosed with nephrotic syndrome last month. Started on
prednisolone —
no remission after four weeks of full-dose therapy.
Persistent heavy proteinuria.
The diagnosis of steroid-sensitive nephrotic syndrome must
now be questioned."
Challenge the diagnosis — return to first principles
Is this steroid-resistant nephrotic syndrome?
Consider FSGS, membranous nephropathy
Renal biopsy indicated?
Revisit haematuria, hypertension, family history.
The framework transfers across every chronic condition in
paediatrics.
The question is never "what is the diagnosis" — it is "is the
diagnosis behaving as it should?" When yes, focus on today. When no,
go back to first principles.
The Rule
There is no point going back
when the diagnosis is
established and behaving.
Excavating the original presentation of a well-established, known
diagnosis wastes time, confuses the listener, and signals a
fundamental misunderstanding of what a case presentation is for.
The past is relevant only when it changes what you think or do
today.
The one exception
Return to first principles when the disease is
not behaving as the diagnosis predicts — failing to
respond to standard treatment, following an atypical course, or
presenting with features inconsistent with the known label. In that
case, the original history is no longer past. It is active clinical
evidence.
Common Errors
What the misapplication looks like at the bedside
Hiding a known diagnosis and reconstructing years of history for a
routine scheduled visit — the diagnosis is not in doubt; this adds
nothing and wastes time
Treating every presentation of a known chronic disease as if the
diagnosis were new — applying Path C logic to a Path A situation
Failing to state the treatment context — "known thalassaemia"
without mentioning the transfusion programme omits critical
information
Not asking "why is this patient here today" before beginning — this
question determines everything; skipping it means the presentation
has no direction
Investigating a deviation without clarifying that the diagnosis
itself is not being challenged — this creates confusion about what
clinical question is being asked
Applying classroom diagnostic-reasoning rules to real ward
presentations — not recognising which context governs the current
situation
Final Take-Home Message
"A presentation serves the patient —
not the exercise."
State what is known.
Focus on why the patient is here today.
Challenge the diagnosis only when the facts demand it.
Everything else is noise dressed as thoroughness.
State the diagnosis
Focus on today
Challenge only when demanded